Tips to make documentation easier, faster, and more satisfying

Current Psychiatry’s malpractice column is evolving. Previously, “Malpractice Verdicts,” used case decisions to initiate discussions of clinical situations that can generate lawsuits. The verdicts remain as “Malpractice Minute”, but Current Psychiatry has invited me to contribute a new column, “Malpractice Rx,” that will solicit questions and address practicing clinicians’ concerns about malpractice risk.

To start this dialogue, I’ll begin with a question that often comes up in discussions with colleagues, and especially when I teach psychiatry residents: “What should I document?” In this article, we will review why proper documentation is essential. We’ll also look at some ideas that might make documentation easier, more efficient, and more satisfying.

When I was in medical school, my professors said the primary reason for accurate charting was to communicate with the rest of the treatment team. This is still true. But in these sadder-but-wiser days, when I ask psychiatry residents “What is the purpose of documentation?” they always answer, “to create a legal record.”

Documentation plays many roles (Table 1). From the standpoint of preventing a malpractice judgment, the clinical record can accomplish 3 important things:

Lawsuit deterrence. Records are a key source—and often the only source—of information an attorney uses when deciding whether to file a lawsuit. An attorney won’t risk time and money on a malpractice case if the clinical record suggests that a psychiatrist was conscientious and met the standard of care.¹

Impression management. The patient’s chart is what plaintiffs’ and defendants’ experts use when forming their initial opinions about the quality of care delivered.

Credibility. Clinical records are the most believable source of information about what you observed, what you thought, what you did, why you did it, and when you did it. The adage “if it wasn’t written, it didn’t happen” is not always applicable,² but if an adverse event occurs, a defendant doctor’s verbal testimony about delivering good care will be more convincing when backed up by documentation created before the event.

Table 1

Purposes of medical record documentation

Improving documentation

Because it is impossible to describe everything you see, hear, say, do, and think during clinical encounters with patients, you must make choices about what to include in the record. The components of good documentation depend on the clinical context, but the following general principles may avert some malpractice actions.

1 More is better. Psychiatric practice often requires you to be discreet about patients’ personal information. Within appropriate bounds, however, the more information the record contains about objective findings, patients’ statements, clinical judgments, and your decision making, the better the portrayal of competent care.

2 Record the time and date. When attorneys and experts try to reconstruct what happened before an adverse occurrence, knowing the exact time you saw the patient, recorded findings, wrote orders, followed up on lab tests, or discussed problems with others—including family and treatment team members—can make a big difference.

3 Sooner is better. The most credible charting is done during or just after a service is rendered. Charting completed after an adverse event is vulnerable to accusations of fabrication.

4 Describe your thinking. Most aspects of clinical medicine are far from certain. Documenting the reasoning behind your diagnosis and treatment selection—what you’ve ruled out, what still seems tentative, and what risks and benefits you’ve weighed—helps emphasize this reality.³ After something bad happens, people retrospectively regard the event as more probable than it really was.⁴ Documenting your uncertainty and ways of addressing it may help counter this “hindsight bias.” It also shows that you were thoughtful and took therapeutic steps prudently.